School Nurse’s Guide to Hand, Foot, and Mouth Disease (HFMD)

I’m gonna tell you a story…it may gross non-nurses out…but I am going to tell it nonetheless. A few years ago, while working as the ADON at a nursing facility, we had a case of Clostridium difficile (klos-TRID-e-um dif-uh-SEEL), often called C. difficile or C. diff. This “young lady,” who having grown up with parents who struggled through the Great Depression and…well…though life, in general, would often use a single square of tissue to “care” for herself then reach out for help up to the sink to wash her hands. She would reach out to either her caregiver (safe), walker (less safe) or bedside table (super dangerous) in order to stand and get to the sink to wash her hands.

The scene is set…then come the call-ins for “diarrhea” and other issues by some of the other nurses and many of the CNAs.

With many of the staff from all the shifts calling in, I quickly put together a meeting to discuss the fundamentals of C. diff. After all, the Q&A sessions that took place to “validate” a call-in revealed quite a bit of information. I wanted everyone to know how important it is to do one thing: WASH YOUR HANDS. Everyone in the meeting seemed to know how important it was to wash their hands. However, something was amiss on Hall 1. Handwashing they knew; washing their hands they did not.

“We have a lot of call-ins and I so appreciate many of you for covering those shifts. But, we need to understand how this illness is spread.” I was talking to many different disciplines and wanted to make sure my message was received on all “levels.” So, I tried to be both professional and simple. “C. diff is passed when someone goes to the bathroom and then touches surfaces like bedside tables that we eventually grab and move without a thought and objects like the coffee cup sitting on the bedside table that we grab and take to the kitchen without a thought or a care…It’s just a bedside table and it’s just a coffee cup. If you touch a surface contaminated with C. difficile spores, you may then unknowingly swallow the bacteria.”

Many in the room just stared at each other looking for an answer other than the one they were only now assuming was true. The “swallow the bacteria” phrase seemed to “wake up” any that were starting to mentally fade from our little meeting. A brave soul from housekeeping raised her hand, “I’m not a nurse and don’t know what that means; how do we ‘swallow the bacteria’.”

I clarified, “You can catch this by getting someone else’s poo poo in your mouth.”

Yes, this is the essence of the fecal-oral contamination route. Of course, most went, “Oh gross!” Some even giggled during the point in the sentence where “poo poo” was mentioned yet the giggling was very short-lived once the “in your mouth” part of the sentence registered. Some even insisted, “I didn’t get no body’s poop in my mouth.” Deny it all you want, but that from which was nestled deep in someone’s bowels has now found its way to your soft oral palate…that’s what fecal-oral means, right? Chris Carter got it right by saying, “The Truth Is Out There.”

This article is not about C-diff (maybe one day). However, this story will work in nicely with this article about Hand, Foot and Mouth Disease (HFMD). Because getting someone else’s poop in in your mouth is one of your many ways HFMD can spread.

What is Hand, Foot and Mouth Disease (HFMD)?

Hand, Foot and Mouth Disease (HFMD) is viral. Yes, the symptoms are caused by Coxackievirus A16 and Enterovirus 71. What does that mean? I’m not sure; that’s a bit above my E-grade (you military folks will get that). It’s a virus and unless you know which virus, the symptoms will likely be the only way to determine which virus is causing the infection because the vast majority of infections are diagnosed by clinical features (we’ll talk about the “clinical features” in just a bit). Yes, there’s a lab test…but it’s seldom ordered (again, more on that later).a

HFMD caused by Coxackievirus A16 is the most common. And thank goodness! HFMD caused by Enterovirus 71 has the potential to be serious. I know that we school nurses have no way of definitively telling which virus is causing the symptoms unless the symptoms have progressed to a more serious state. The purpose of this information is to plant that little seed so you can assess not only the probable but also the improbable. In the symptoms section, I’ll talk about what the Enterovirus 71 is capable of.

How do we catch HFMD?

I’d tell you that all you have to do to keep from catching HFMD is to wash your hands. But it’s not that simple.

Most infections occur in children under about 10 or 11-years-old. Don’t get too comfortable as a Middle School or High School nurse; these children get it too (and so do school nurses and teachers). Children are not the only “critters” that put their hands in their mouth.

The virus is spread by getting into our bodies (usually via the unwashed hands) after coming into contact with someone’s runny nose drainage, saliva, fluid from a blister and/or stool (remember the story above?). Also, an infected person can spread the infection as tiny droplets are sprayed into the air during coughing or sneezing . These tiny droplets are shot out of their mouths and schnozzes (noses) and these droplets make contact with someone else’s mouth or schnozzes thereby potentially causing the other person to become sick with HFMD. We mentioned getting poop in your mouth (the fecal-oral route), but getting someone’s slobber in your mouth is pretty gross too (stay with me…you know what I mean). Getting someone else’s snot and spit in my mouth, nose, eyes or even on the tip-tops of my fingers is pretty yucky. But then again, I digress…

What are the symptoms of HFMD?

After the short incubation period (1 or 2 days and sometimes as long as 5 days) the person will present with a fever, show little or no interest in food and have a sore throat. It may look like a cold or the start of the flu. Not that it is a sure-fire way to know early HFMD symptoms versus flu and cold symptoms, but HFMD will more likely show up during the warmer months whereas cold and flu symptoms show up during the cooler months. But this is just a generality that should not rule out either HFMD or the Flu. It’ll just be an observation if someone presents with cold-like or flu-like symptoms in August or some other warm, non-flu season time of the year.

About 2-3 days later, the findings will be more clear. If the child is ill with HFMD, and after the initial symptoms have started, a blister-like rash on the hands, feet and in/around the mouth may develop. This will be more of a tale-tell than the initial, flu-like / cold-like symptoms.

The doctor will diagnose HFMD by the clinical findings and will seldom order a confirmation laboratory test (which costs money and takes time). By the time the test comes back, the symptoms will be subsiding and the child will be on the mend and less contagious (respiratory shedding of the virus usually last about 1 week (but can last for 3 weeks)). However, the child may remain contagious for a bit of time afterward this 1-week period. The virus can be shed via the child’s fecal matter for many weeks after the child appears to have resolved.

If you are asking, “Why not get a test to see if the child has HFMD because they the “virus can be shed via the child’s fecal matter for many weeks,” consider the fecal matter itself. I am pretty sure you see where I am going with that…

All-in-all, the illness is short-lived and will resolve rather quickly.

With any case of HFMD, we school nurses will “see” the illness under the paradigm of Occam’s razor and assume the most likely explanation. Even though most of the time the simplest explanation is the right explanation, assessing for the unlikely is ALWAYS good nursing practice. If the child is infected with Enterovirus 71 (EV71 or E-71), the symptoms will be much more profound the outcome…well…assess for symptoms of meningitis and/or encephalitis.

Symptoms of Meningitis

If you see a child with a fever, severe headache, and neck stiffness (especially a sudden onset) with or without other symptoms associated with HFMD, you may be dealing with an EV71-caused meningitis. It’s that “neck stiffness” that gets the “nursing senses” going. Continue to assess for:

Confusion and disorientation (acting “goofy”)

Agitation and/or mental status changes

Drowsiness or sluggishness

Sensitivity to bright light

Seizures

Symptoms of Encephalitis

Encephalitis is inflammation of the brain.

You’ll see good, ol’-fashion flu-like symptoms (when do we not see “flu-like symptoms?”) including headache, fever, body aches and being tired, fatigued or weak-feeling. Really get to looking when you see things like:

If you see these symptoms, consider that the child’s HFMD may be due to EV71 and not the much more common Coxackievirus A16. HFMD by EV71 is rare but very dangerous.

How do we treat HFMD?

First of all, dehydration is a big issue with those suffering from HFMD; the sores in the mouth and throat can make swallowing very uncomfortable and maybe a little difficult. Teach the child and the child’s guardian to take/offer small bits of water (or other liquids the child can tolerate) often during the day.

From that, there’s only a couple of things that can be done: Watch and Wait. If the child is infected with Coxackievirus A16, the treatment is simple: manage symptoms and promote excellent hand hygiene.

What does the school nurse do when they think they have a case of HFMD?

The Infected:

First and foremost, promote hand washing. Encouraged the child to wash their hands often. The child with HFMD should wash their hands after coughing, sneezing regardless if a tissue or a sleeve is used.

Though we school nurses can not officially diagnose HFMD, we school nurse are able to identify a symptoms and to treat the symptoms within the limitations of the nurse’s credentials and the care setting ie: the school’s health office. We are also able to make decisions that are both best for the infected child and the other children and school faculty.

Do we exclude?

To exclude or not to exclude…that is a tricky one. Let me ask a question to the ones that say “do not exclude.” Consider the Flu. Regardless of the risk of transmission from one child to another (which is a big reason in and of itself), what keeps the child out of school? The flu itself does not keep the child out of school; it’s BOTH the risk of infecting others AND the flu symptoms themselves that keeps the child out of school. A dehydrated, feverous, uncomfortable, lethargic child with no energy and a lack of an appetite (not to mention the possible diarrhea and vomiting) is in no physical or emotional state to learn or to participate in school.

If HFMD is causing flu-like symptoms that keep the child from participating in the school day’s agenda – Exclude

If the blister-like rash on the hands, feet and in/around the mouth are weeping fluid and the blister-like rash cannot be covered – Exclude

If coughing and sneezing cannot be controlled or the child is not at the level of understanding as to how to properly “cover the cough” or cover the sneeze – Exclude

If the child has a fever of 100°F [38.7°C] or higher – Exclude

If you suspect infection by EV71 – Exclude

If your nursing gut-feeling says “exclude” – Exclude

There are other reasons to exclude but the last one is always the one I go with. If it’s not safe for the sick child, the other children or the faculty members teaching / caring for the child, I suggest the child stay home and to seek a more definitive diagnosis and plan of care (including when to return to school) by the physician.

Nurse Kevin is a school nurse who takes care of school children in Southwestern Idaho. Nurse Kevin authors content for many different websites including goseethenurse.com, licebattleplan.com, backtothehomestead.com, jesusbuiltonechurch.com, idahoismyhome.com, nursekevinhomes.com.

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Every child coming into my office is looking for something. They may have a bump, bruise or scratch that I can plainly see. Or maybe they have a “stomachache” because they know that their turn to read aloud in class is coming up and they fear not doing well. Every child has something they are experiencing when the go see the nurse and it’s my prayer that their need is fulfilled when they leave the nurse. Even my “fakers” get a peppermint when they Go See The Nurse.